Evidence-based hip fracture surgery

This thesis focuses on improving evidence-based decision-making in orthopaedic trauma care for elderly patients with femoral neck fractures treated with hemiarthroplasty. It first examines proxy assessments of health-related quality of life and identifies which proxy perspective provides the most reliable assessment, while also showing that proxies generally underestimate patients’ self-reported health status.
Long-term follow-up of a randomized trial comparing hemiarthroplasty with total hip arthroplasty showed comparable functional outcomes after 12 years, supporting hemiarthroplasty as a suitable treatment option in selected elderly patients. A systematic review demonstrated that existing evidence comparing the direct lateral approach (DLA) and posterolateral approach (PLA) for hemiarthroplasty was of very low quality, emphasizing the need for robust comparative research.
This led to the APOLLO trial, a large multicentre randomized controlled trial combined with a natural experiment. The trial showed no significant difference in health-related quality of life between DLA and PLA six months after surgery, while PLA was associated with a higher risk of dislocation and reoperation. Importantly, comparison of the randomized controlled trial and natural experiment showed that, in this trauma setting, pseudo-randomization produced results consistent with traditional randomization. This suggests that natural experiments may offer a reliable alternative to randomized controlled trials in selected research settings.
Additional analyses showed no significant difference in physical performance between DLA and PLA. The economic evaluation found no clear cost-effectiveness advantage of DLA. Overall, this thesis provides evidence to guide surgical decision-making and future research in hip fracture care.